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Specialty Drug List 08-24-10

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Specialty Drug List 08-24-10 Iowa Medicaid Specialty Drug List Effective 10/18/2010 “Specialty” drugs include biological drugs, blood-derived products, complex molecules, and select oral, injectable, and infused medications identified by the Department and reimbursed at AWP-17% plus the dispensing fee. Specialty pricing will be applied to both the brand and generic drug products. NOTE: See the PDL at www.iowamedicaidpdl.com for specific PA criteria for the following drugs. BRAND NAME GENERIC NAME ALS RILUTEK riluzole ALCOHOL DEPENDENCE VIVITROL naltrexone AMINOGLYCOSIDES TOBI tobramycin ANTI-ASTHMATICS ALPHA PROTEINASE INHIBITORS PROLASTIN, C proteinase inhibitor ARALAST NP proteinase inhibitor ARALAST proteinase inhibitor ANTIASTHMATIC - BETA - ADRENERGICS BRETHINE INJECTION turbutaline sulfate ANTIBIOTICS - MISC. CAYSTON aztreonam lysine for inhal soln ANTI-CATAPLECTIC AGENTS XYREM sodium oxybate oral solution ANTICOAGULANTS FRAGMIN dalteparin sodium LOVENOX enaxoparin sodium INNOHEP tinzaparin sodium ARIXTRA fondaparinux sodium ANTIDOTES - CHELATING AGENTS EXJADE deferasirox tab for oral susp CHEMET succimer ANTIHEMOPHILIC AGENTS ADVATE factor 8 ALPHANATE factor 8 ALPHANINE SD factor 9 AUTOPLEX T anti-inhibitor coagulant complex BEBULIN VH factor 9 - complex human BENEFIX factor 9 - recombinant BIOCLATE antihemophilic factor FEIBA VH IMMUNO anti-inhibitor coagulant complex HELIXATE FS factor 8 HEMOFIL M HUMAN factor 8 HUMATE-P factor 8/vrcof KOATE-DVI factor 8 KOGENATE factor 8 KOGENATE FS INJ factor 8 MONARC-M factor 9 MONOCLATE-P factor 8 MONONINE factor 9 NOVOSEVEN factor 7a recombinant NOVOSEVEN RT INJ factor 7a recombinant PROFILNINE SD factor 9 PROPLEX T FACTOR IX COMP factor 9 RECOMBINATE factor 8 REFACTO factor 8 XYNTHA factor 8 ANTIINFLAMMATORY AGENTS XOLAIR omalizumab ANTILEPROTIC Page 1 of 7 THALOMID thalidomide ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS ZINECARD dexrazoxane for injection ANTINEOPLASTICS - COMBINATIONS IFEX/MESNEX COMBO PACK ifosfamide & mesna injection kit ANTINEOPLASTICS - ESTROGEN RECEPTOR ANTAGONIST FASLODEX fulvestrant injection ANTINEOPLASTICS - ESTROGENS EMCYT estramustine phosphate sodium ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS RESCUE AGENTS leucovorin calcium leucovorin calcium ANTINEOPLASTICS - IMIDAZOTETRAZINES TEMODAR temozolomide ANTINEOPLASTICS - INTERLEUKINS PROLEUKIN aldesleukin for IV solution ANTINEOPLASTICS - LHRH ANALOGS TESLAC testolactone ZOLADEX goserelin acetate implant LEUPROLIDE INJ leuprolide acetate injection LUPRON DEPOT-PED leuprolide acetate for injection pediatric kit LUPRON DEPOT leuprolide acetate for injection kit TRELSTAR DEPOT triptorelin pamoate for IM susp TRELSTAR LA triptorelin pamoate for IM susp degarelix injection FIRMAGON degarelix injection ELIGARD leuprolide acetate PLENAXIS abarelix VANTAS histrelin acetate ANTINEOPLASTICS - MISC. ALFERON N interferon alfa-n3 MATULANE procarbazine hci ROFERON-A interferon alfa-2a INTRON-A W/DILUENT interferon alfa-2a INTRON-A interferon alfa-2a ACTIMMUNE interferon gamma-1b DROXIA hydroxyurea REVLIMID lenalidomide XELODA capecitabine ANTINEOPLASTICS - MITOTIC INHIBITORS TAXOTERE docetaxel for injection TOPOSAR etoposide TAXOL paclitaxel IV conc ABRAXANE paclitaxel protein-bound particles for IV suspension VINCASAR PFS vincristine sulfate iv solution 1 mg/ml vinblastine sulfate vinblastine sulfate for injection NAVELBINE vinorelbine tartrate injection ANTINEOPLASTICS - NITROGEN MUSTARDS LEUKERAN chlorambucil cyclophosphamide cyclophosphamide CYTOXAN cyclophosphamide for injection ALKERAN melphalan melphalan hydrochloride melphalan hydrochloride ANTINEOPLASTICS - NITROSOUREAS GLIADEL carmustine in polifeprosan intracranial implant wafer Page 2 of 7 GLIADEL WAFER carmustine in polifeprosan intracranial implant wafer CEENU lomustine ANTINEOPLASTICS - PROGESTINS DEPO-PROVERA 400 mg/ml medroxyprogesterone acetate MEGACE ES megestrol acetate susp ANTINEOPLASTICS - PROTEIN - TYROSINE KINASE INHIBITORS ZOLINZA vorinostat AFINITOR TAB everolimus NEXAVAR sorafenib tosylate SUTENT sunitinib malate SPRYCEL dasatinib TARCEVA erlotinib IRESSA gefitinib GLEEVEC imatinib mesylate TYKERB lapatinib ditosylate VELCADE bortezomib for injection TASIGNA nilotinib VOTRIENT pazopanib ANTINEOPLASTICS - RETINOIDS VESANOID tretinoin ANTINEOPLASTICS - SELECTIVE RETINOID X RECEPTOR AGONISTS TARGRETIN bexarotene ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS CAMPTOSAR sunitinib malate HYCAMTIN topotecan hcl for injection ANTINEOPLASTICS - URINARY TRACT PROTECTIVE AGENTS ETHYOL amifostine MESNEX mesna ANTIRETROVIRALS SELZENTRY TAB maraviroc ISENTRESS raltegravir potassium PREZISTA TAB darunavir ethanolate EPZICOM abavir sulfate-lamivudine TRUVADA emtricitabine-tenofovir disoproxil fumarate ATRIPLA efavirenz emtricitabine-tenofovir df ANTIRETROVIRALS - FUSION INHIBITORS FUZEON enfuvirtide for injection ANTIRETROVIRALS - PROTEASE INHIBITORS AGENERASE amprenavir ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES RESCRIPTOR delavirdine mesylate SUSTIVA efavirenz INTELENCE etravirine VIRAMUNE nevirapine ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PURINES ZIAGEN abacavir sulfate VIDEX didanosine VIDEX EC didanosine delayed release capsule Page 3 of 7 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PYRIMIDINES EMTRIVA emtricitabine EPIVIR HBV lamivudine EPIVIR lamivudine HIVID zalcitabine ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES VIREAD tenofovir disoproxil fumarate BIOLOGICALS AMEVIVE alefacept for intravenous injection CIMZIA certolizumab pegol ENBREL etanercept ENBREL SURECLICK etanercept HUMIRA adalimumab HUMIRA PEN adalimumab KINERET anakinra ORENCIA abatacept REMICADE infliximab recombinant RITUXAN rituximab SIMPONI golimumab STELARA ustekinumab CMV CYTOGAM cytomegalovirus immune globulin CYTOVENE ganciclovir FOSCARNET foscarnet VALCYTE valganciclovir VISTIDE cidofovir IV Inj CRYOPYRIN ASSOCIATED PERIODIC SYNDROMES ILARIS canakinumab ARCALYST rilonacept ERYTHROPOEISIS STIMULATING AGENTS ARANESP darbepoetin alfa-polysorbate EPOGEN epoetin alfa injection PROCRIT epoetin alfa injection FABRY DISEASE FABRAZYME agalsidase FIBRINOGEN CONCENTRATE RIASTAP fibrinogen GAUCHER DISEASE CEREZYME imiglucerase ZAVESCA miglustat GI - ANTIPERISTALTIC AGENTS OPIUM TINCTURE opium tincture GI - DIGESTIVE ENZYMES SUCRAID sacrosidase solution GLUCOCORTICOIDS-CORTICOTROPIN ACTHAR HP corticotropin GRANULOCYTE CSF NEUPOGEN filgrastim injection NEULASTA pegfilgrastim injection LEUKINE sargramostim lyophilized for injection NEUMEGA oprelvekin for injection GROWTH HORMONE GENOTROPIN somatropin GENOTROPIN INTRA-MIX somatropin GENOTROPIN MINIQUICK somatropin HUMATROPE somatropin HUMATROPE COMBO PACK somatropin INCRELEX mecasermin IPLEX mecasermin rinfabate NORDITROPIN CARTRIDGE somatropin Page 4 of 7 NORDITROPIN NORDIFLEX PEN somatropin NUTROPIN AQ somatropin NUTROPIN AQ PEN somatropin NUTROPIN DEPOT somatropin NUTROPIN INJ somatropin OMNITROPE INJ somatropin PROTROPIN somatrem SAIZEN somatropin TEV-TROPIN somatropin ZORBTIVE somatropin HEPATITIS B ONLY HEPSERA adeforvir dipivoxil BARACLUDE entecavir TYZEKA telbivudine HEPATITIS C AGENTS COPEGUS ribavirin INFERGEN interferon alfacon-1 PEGASYS peginterferon alfa 2a PEG-INTRON interferon alfa 2b PEG-INTRON REDIPEN interferon alfa 2b REBETOL ribavirin REBETRON ribavirin RIBAPAK ribavirin RIBAVIRIN ribavirin HEREDITARY ANGIOEDEMA CINRYZE C1 inhibitor HEREDITARY TYROSINEMIA ORFADIN nitisinone HOMOCYSTINURIA CYSTADANE betaine HUNTER SYNDROME ELAPRASE idursulfase HYDROLYTIC ENZYMES PULMOZYME dornase alpha HYPERCALCEMIA GANITE gallium HYPERPARATHYROIDISM SENSIPAR cinacalcet ZEMPLAR paricalcitol IMMUNE SERUMS/IVIG ADAGEN immune globulin CARIMUNE immune globulin FLEBOGAMMA immune globulin GAMMAGARD immune globulin GAMMAGARD SD immune globulin GAMUNEX immune globulin OCTAGAM immune globulin PANGLOBULIN immune globulin PRIVIGEN immune globulin VIVAGLOBIN immune globulin IMMUNOSUPPRESSANTS CELLCEPT mycophenolate CYCLOSPORINE cyclosporine GENGRAF cyclosporine MYCOPHENOLATE mycophenolate MYFORTIC mycophenolic acid NEORAL cyclosporine PROGRAF tacrolimus RAPAMUNE sirolimus SANDIMMUNE cyclosporine ZENAPAX daclizumab IRON PARENTERAL Page 5 of 7 FERRLECIT sod. ferric gluc cmplx sucrose VENOFER iron sucrose LINCOSAMIDES/OXAZOLIDINONES/LEPROSTATICS CUBICIN daptomycin ZYVOX linezolid MUCOPOLYSACCHARIDOSIS ALDURAZYME laronidase NAGLAZYME galsulfase MULTIPLE SCLEROSIS AGENTS AMPYRA dalfampridine EXTAVIA interferon beta-1b for injection MULTIPLE SCLEROSIS AGENTS - INTERFERONS REBIF interferon beta-1a injection REBIF TITRATION PACK interferon beta-1a injection AVONEX interferon beta-1a for IM injection BETASERON interferon beta-1b for injection MULTIPLE SCLEROSIS AGENTS - NON-INTERFERONS COPAXONE glatiramer acetate NARCOTICS - MISC. ACTIQ fentanyl citrate PRIALT ziconotide OSTEOPOROSIS AREDIA pamidronate BONIVA INJ ibandronate FORTEO teriparatide PAROXYSMAL NOCTURNAL HEMOGLOBINURIA SOLIRIS eculizumab PHOSPHODIESTERASE INHIBITORS MILRINONE milrinone lactate IV solution PKU KUVAN sapropterin POMPE DISEASE MYOZYME algucosidase alfa PULMONARY ANTI-HYPERTENSIVES ADCIRCA tadalafil EPOPROSTENOL epoprostenol FLOLAN epoprostenol LETAIRIS ambrisentan REVATIO sildenafil TRACLEER bosentan VENTAVIS iloprost REMODULIN treprostinil sodium TYVASO treprostinil sodium RHEUMATOID ARTHRITIS - BIOLOGICALS ACTEMRA tocilizumab IV injection RSV PROPHYLAXIS SYNAGIS palivizumab SOMATOSTATIC AGENTS SANDOSTATIN octreotide acetate inj SANDOSTATIN LAR DEPOT octreotide acetate for IM inj SOMAVERT pegvisomant for injection Page 6 of 7 THROMBOPOEITIN RECEPTOR AGONISTS NPLATE romiplostim PROMACTA eltrombopag UREA CYCLE DISORDERS BUPHENYL sodium phenylbutyrate AMMONUL sodium benzoate VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA tolvaptan Page 7 of 7.
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